AUA, allies critical of GAO self-referral report

Washington-Major organizations representing urology are livid at the conclusions of a new report by the U.S. Government Accountability Office (GAO), which basically accuses urology practices with in-office intensity-modulated radiation therapy (IMRT) facilities of ripping off Medicare.

The report, issued Aug. 1, says that Medicare providers that self-referred IMRT services, especially those in limited-specialty groups, “were substantially more likely to refer their prostate cancer patients for IMRT and less likely to refer them for other, less costly treatments, especially brachytherapy or a radical prostatectomy, compared to providers who did not self-refer.”

GAO said it also found that after providers began to self-refer IMRT services, they “substantially increased the percentage of their prostate cancer patients they referred for IMRT, while providers that did not begin to self-refer experienced much smaller changes over the same period.”

Taken together, GAO declared, “Our findings suggest that financial incentives were likely a major factor driving the increase of IMRT referrals among self-referring providers in limited-specialty groups.”

AUA, LUGPA, AACU dispute findings

The AUA, Large Urology Group Practice Association (LUGPA), and American Association of Clinical Urologists (AACU) all denied that urologists who refer patients to their own IMRT facilities do so for financial reasons at the detriment of Medicare or their patients.

They also disagreed with GAO’s argument that, “To the extent that providers’ financial interests are shaping treatment decisions, some patients may end up on a treatment course that does not best meet their individual needs,” and that “because IMRT costs more than most other treatments, the higher use of IMRT by self-referring providers results in higher costs for Medicare and beneficiaries.”

GAO said Congress should consider directing the Department of Health and Human Services (HHS) to require providers who self-refer IMRT services to disclose to their patients that they have a financial interest in the service. They also recommended that the Centers for Medicare & Medicaid Services insert a self-referral flag on Medicare Part B claims forms requiring providers to indicate whether the IMRT service being billed is self referred, and to monitor the effect of self-referral on costs and beneficiary treatment selection. HHS responded by saying that a self-referral flag would not be helpful and that tracking self-referral would be complex to administer and may have unintended consequences.

The report’s release was immediately followed by a news conference by Rep. Jackie Speier (D-CA), who announced introduction of the “Promoting Integrity in Medicare Act of 2013.” The bill would remove physical therapy, advanced imaging, radiation oncology, and anatomic pathology from the in-office ancillary services exception (IOAE) to the federal Stark self-referral law.

Organized urology is working to maintain that exception, which the organizations contend helps to keep costs down and provides for more convenient coordinated care for patients.

Report ‘does not reflect the facts’

“The GAO report does not reflect the facts,” declared LUGPA President Deepak A. Kapoor, MD, who pointed out that GAO did not recommend ending the IOAE, nor did it recommend limiting the ability of urologists to provide comprehensive and integrated cancer care.

In a joint statement, the AUA, LUGPA, and AACU said GAO “provided no evidence that patients were being provided radiation therapy inappropriately by integrated urology practices that had acquired IMRT.”

Dr. Kapoor, CEO of Integrated Medical Professionals, PLLC, a multispecialty physician group operating in the greater New York metropolitan area, said cancer care “is most optimally delivered in a comprehensive, integrated fashion in which shared decision making is enhanced by patient exposure to providers of differing disciplines who can offer views based on their clinical expertise and experience.”

He said GAO disregarded the fact that the increase in the overall number of IMRT treatments performed by urology groups is directly related to the fact that the number of these groups has increased dramatically in recent years.

He also said GAO “completely disregarded peer-reviewed literature that demonstrates that IMRT has become the clinical standard of care for prostate cancer patients and that patient understanding of their treatment options is substantially enhanced when there is shared decision making in a comprehensive, integrated cancer care setting-which results in patients choosing equally effective, less-invasive forms of cancer therapy.”

“Complete and utter nonsense,” was how Dr. Kapoor described GAO’s statement that physicians who refer patients to their IMRT facility are leading patients to treatment that may not be best for them.

“If you are over 65 years old, a Medicare patient, and I told you that you have a choice between two forms of therapy with an identical outcome, and that one will involve surgical procedures and dangers and the other provides the exact same result but you can continue to live your life with a lower complication rate, which would you choose? The literature shows that if a patient consults with his urologist, 80% are going to choose noninvasive therapy.”

Among the organizations issuing statements in support of GAO’s report and Speier’s bill were the American Society of Radiation Oncology, the College of American Pathologists, and the American Physical Therapy Association.UT

Subscribe to Urology Times to get monthly news from the leading news source for urologists.